Hearing of the Senate Foreign Relations Committee - The Next Phase of the Global Fight Against HIV/AIDS
SEN. BIDEN: The hearing will come to order. I apologize to my colleagues for being late. I won't even try to explain where I was. You won't believe me, so I'll keep - but anyway, all kidding aside, I do apologize for the late start.
(Off mike.) Are we short of a quorum? (Confers with staff.)
We are short one for a quorum, but what I'd like to do is make my very brief opening statement, yield to the Senator, and then the agenda, as you'll see, is not - there may be one outstanding bit of controversy, but I don't think there's much controversy in the - on the agenda.
I believe we have 22 nominations on the agenda today and I believe we can probably voice-vote on all of them, except one. Senator Nelson has requested a roll-call vote on the nomination of Henrietta Fore to be the administrator for the Agency for International Development. And I hope we can do this quickly because I'd like us to get on with the hearing on HIV/AIDS program with the ambassador.
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SEN. BIDEN: Thank you very much, gentlemen. The nominating executive session is ended and we'll now take a second and go straight to the hearing on the AIDS.
SEN. BIDEN: The hearing will come to order. We now turn to a hearing on "The Next Phase of the Global Fight Against HIV/AIDS." And our witness, and we welcome him, is Ambassador Dybul.
Welcome, sir. Thank you for being here.
This is the first of several hearings this committee will hold to explore the critical question which is, where do we go next on the global fight against HIV/AIDS? Nearly three million people died because of AIDS last year. And nearly 40 million people are living with HIV today, and most of them don't know because they've never been tested.
Six thousand people will become newly-infected today - 6,000 in a single day - 6,000 every single day. That is the relentless enemy that we're up against. We have made tremendous gains in the last four years in the fight against HIV/AIDS but these numbers tell us just how far we still have to go.
Four years ago, Congress passed the United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act. We authorized $15 billion to support the President's Emergency Plan for AIDS Relief, and for the Multilateral Global Fund to Fight AIDS, Tuberculosis and Malaria. That legislation launched a five-year battle plan in the war on AIDS, TB and malaria.
Since then, the United States has created the largest public health program the world has ever known. And I believe history will record that this is one of President Bush's greatest accomplishments. He has helped to save millions of lives by leading the global fight against HIV/AIDS, and by spearheading a new malaria initiative.
Thanks to international efforts led by the United States, over a million people with AIDS are now on antiretroviral treatment, or ARVs. That means over a million death sentences have been suspended, but that's still less than a quarter of those who need treatment in poor and middle income countries. Enrolling more people into treatment programs, and maintaining efforts already underway, is a substantial challenge. So is helping the countries that begin to assume ownership of these efforts on the road to sustainability.
Thanks to U.S. programs designed to prevent the transmission of HIV from mother to child, since 2003 over half a million pregnant and nursing women have received treatment. As a result, over 100,000 babies who likely would have contracted HIV, did not. Every healthy baby today is a triumph. But we cannot declare victory. Far from it, because the disease continues to spread. Every day, 1,800 children world-wide become infected with AIDS. The vast majority are newborns in Sub-Saharan Africa whose mothers were infected and lacked the means to protect their children.
We are not keeping pace with this pandemic. For every person who enrolled in a treatment program last year, six more became newly infected. The United States and its partners need to devote more funds for this effort. But it's not just a question of more money, it's a question of how we spend it. These are the facts before us, and as the committee takes up the reauthorization of our global HIV/AIDS, TB and malaria programs, these must be kept in mind. This will be a bipartisan effort, and I look forward to working with Senator Lugar, as well as other members of the committee, and Senator Kennedy - Senators Kennedy and Enzi, on the Health, Education and Labor committees.
In thinking about reauthorization -- for myself, speaking only for myself, I have several priorities. The first priority is simply this: we have to reauthorize this bill. No one - no one should doubt the bipartisan commitment of this Congress to see the process through. It's more important that we do this right, than we do it overnight. But we will reauthorize this legislation.
Second, in reauthorizing the bill we must do more on prevention. The math is brutally clear: we cannot keep up with the current pace of the epidemic through treatment programs. To slow its deadly progress, we have to expand and improve the prevention efforts.
Third, we should follow the recommendations of the Government Accountability - Accounting Office and the Institute of Medicine, which is part of the National Academies of Science. In a Congressionally-mandated report, the Institute of Medicine recommended eliminating current budget allocations, or earmarks, that limit vital flexibility. We currently have 15 AIDS focused - AIDS focus countries. That means we are not facing a single pandemic, but rather 15 or more local epidemics -- what works in Botswana may not work in Nigeria or Vietnam.
We need to give those who are fighting the battle against HIV/AIDS the flexibility to combat their local epidemics. We should have targets and mechanisms to measure progress, but we should not divide our funding into rigid, arbitrary categories that dictate our priorities.
And finally, we need to listen to the people on the front lines of this fight. This summer, Senator Lugar and I asked the staff committee to visit these countries and look at the programs -- and in the dozens of focus countries, to assess their progress and problems; to talk to care-providers and patients; to consult with government officials and NGOs. Their findings will help us strengthen the program.
My other key priorities for reauthorization are: better integrate our HIV/AIDS effort with other health and development programs; two, build healthy capacity in Africa -- the shortage of health care workers may be the greatest obstacle in the fight against HIV/AIDS on the continent of Africa; we have to, thirdly, expand our efforts to address the gender-based violence and other inequities -- millions of women and girls do not have the power to make sexual decisions, abstinence is not an option when you lack the power to choose, girls' education and women's empowerment, in my view, are critical in the fight against AIDS; and fourth, we have to improve our efforts to combat TB and malaria -- these diseases were a part of the 2003 legislation, they should be part of our discussion now.
Finally, as we work to reauthorize this legislation we should expand funding for it. The president has called on Congress to pass a bill authorizing $30 billion over the next five years. He has called this a "doubling of our efforts." That does amount to doubling the initial authorization, but not our current funding.
Foreign Operations appropriations bill recently passed by the Senate includes $5.7 billion for AIDS, TB and malaria for Fiscal Year '08. If we divide $30 billion over the next five years, it would provide for $6 billion a year, a relatively small increase over our current efforts -- not a doubling. I believe that $30 billion should be the starting point for our discussion, not our final destination.
The fight against HIV/AIDS, TB and malaria is one of the great moral strategic challenges of our time. Congress must once again rise to the challenge, building on and improving the legislative framework we laid out in 2003. We're in this for the long-haul and reauthorizing this bill will be the next step.
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SEN. BIDEN: Thank you, Mr. Ambassador. You can assure I believe with certainty any health official in any nation that is benefiting from this program that it will be continued.
And let me ask, the president's goal of target for the next five years would add 500,000 people to the original target of putting 2 million people on treatment by 2008. Would additional funding help us achieve more?
MR. DYBUL: I think for prevention, treatment and care resources are an important piece of the puzzle, as is building health capacity. And I think we're all aware that as the president called for 30 billion (dollars) for PETFAR, the G8 has committed $60 billion but they included TB and Malaria. So for the next five years at that 30 billion (dollars) we would actually be more than the rest of the developed world combined. So we think for going forward for issues of sustainability and expansion of care and treatment is necessary, but the goal actually for the second five years as the president has called for actually a little bit heavier on prevention. It actually calls for about a doubling of the prevention goal -- as you pointed out prevention being the most important piece while we increased care and treatment 20 to 25 percent.
So I believe the answer to your question is the additional resources could increase but they don't necessarily have to come from the American people which is why we're turning to the world community as well. And we believe that about if we're going to be more than half of the rest of the world that puts us in about the right situation going forward.
SEN. BIDEN: Okay.
Obviously one of the controversial pieces of the original legislation was the abstinence piece. And it's still debated somewhat heavily. And you pointed out that you have observed and tried to accommodate the cultural differences from country to country and how best to attack this pandemic -- this epidemic in the countries.
And in some parts of the world, there's some devastating statistics relative to consensual sex versus nonconsensual sex. Between 20 and 50 percent of women in the countries under consideration -- or that are involved, indicate that their first sexual experience was forced. Nearly 50 percent of all sexual assaults in these countries are committed against girls 15 years or younger. Excuse me -- and obviously violence puts women and girls at a higher risk of HIV. One study that you describe in your 2006 report to Congress found that in Tanzania, young HIV positive women were 10 times more likely to report violence than HIV negative women.
Now, obviously, we're not going to reach our goals around prevention, care and treatment if -- I shouldn't say obviously, it's my view that we will not meet them if we don't address this -- how gender-based violence is impacting on it.
The president's emergency plan is making real strides forward but you've stated obviously we have to do more. How much money do our programs now spend to prevent or help people recover from gender-based violence? Is it a focus at all?
MR. DYBUL: As a matter of fact, Senator -- Mr. Chairman, it is a focus.
We actually are focused on gender inequality in general, not just gender-based violence because the gender-based violence really is a part of culture, our gender inequality that promotes gender violence; it also promotes transgenerational sex where older men have sex with younger women or younger boys prey on younger girls, so it's a whole deep cultural issue. So we're trying to address the broader issue and gender-based violence as a piece of a multi-pronged approach to address these issues.
I agree we can do more. And I must admit, it's going to be very difficult for an AIDS initiative to radically change all the cultural aspects but we're trying to do our piece here. We dedicated around $442 million last year for programs that had a gender component to them.
I think the fundamental thing though, is changing gender norms. And so that's why we begin with these life skills programs at an early age to try to change the whole dynamic to teach children to respect themselves, to respect others which includes respecting girls. And it's a generational approach that's going to take time.
At the same time, we're engaged in gender-based violence. We work with the women's justice and empowerment initiative to deal with some of these issues, provide post-exposure prophylaxis, provide counseling and testing around gender-based violence. It's a very complicated approach. I think you're correct, in such a situation whether it's violence or other gender inequality, negotiating abstinence is very difficult but it's as difficult to negotiate a condom. So it's actually important that we address the gender norm overall. And it's going to take time. But we're seeing great success.
I'll give you an anecdote which I think reflects it. I went to a high school in Botswana where we had begun these life skills programs to change the dynamic, to teach people to respect each other. And this program had been going on for a little over a year, now we're expanding it throughout the country as we're doing in many other countries. And we asked -- we got a small group of them after and began asking some questions. The girls answered all of the questions. And the girls talked about how they wanted to become doctors and engineers. That's not normal in an African situation. Normally the boys would dominate, the girls would be quiet. That's the type of thing we're trying to foster and change which we then think will influence gender-based violence. But also we need direct programs on gender-based violence.
Again, I think we can improve everything we're doing. It's definitely a focus for us. And we're doing some innovative programs and evaluating them to see what the greatest outcome is including job creation and some other things to see if we can change this whole dynamic. But we've got to work with USAID; we've got to work with the Millennium Challenge Corporation; we've got to work with the countries themselves.
It's one of the reasons going forward we talked about this partnership compacts, we would actually work with countries to help them deal with gender inequality because we agree with you, we can't tackle this problem if we don't deal better with inequality.
SEN. BIDEN: The reason -- I'm impressed by your answer. And this first round is seven minutes and my time is almost up -- but let me just ask this question, obviously it would -- what I'm about to ask is not something that would be funded thorough PETFAR but if you know -- if you don't know for sure, you can take an educated guess -- what percentage of the countries that are recipients of this assistance have universal elementary school education and includes women?
MR. DYBUL: I'd actually have to double check. Most of them do actually have universally available primary education. The problem is when they do that, they have school fees or uniform fees which limits the ability kids to go. And then there's not much secondary schooling so they end at primary school. We're actually developing through our orphans program with the African education system scholarship programs to get kids through secondary school. I have to get you a specific answer, but many of them do, but on paper might be different than the actual --
SEN. BIDEN: Generically, do you think that if -- assuming we had unlimited which we don't, unlimited money to deal with foreign aid -- if we were to direct more of our economic aid to the countries in question toward building and sustaining and funding their elementary and secondary education systems that required the same treatment for young boys as young girls in that system -- is that likely to have any positive impact on what we're talking about here?
MR. DYBUL: It's something we intend to look at. I don't know. You could say that it would and it very well might but we're not 100 percent certain so we want to evaluate that -- implement programs and then evaluate it. I should point at that there are other players in this field. The United Kingdom has --
SEN BIDEN: Well, I realize that.
MR. DYBUL: Yeah.
SEN. BIDEN: I was just wondering what our thinking was.
MR. DYBUL: Right. So we want to work with all of these different players to basically put the pieces of the puzzle together and see how we can have the greatest impact.
SEN BIDEN: Well, what I'm about to say -- and I'm 30 seconds over my time already, I don't want you to respond now -- what I'm about to suggest is not something that I would attempt to attach to this legislation. But I have a bill that's an international violence against women act, money promoting, like we did here, promoting domestically in the violence against women act, money made available to countries who would engage in certain activities that would in fact promote efforts to diminish violence against women in these various societies.
And I'd like to because you seem to be -- and it's not in your will house, it's not in your secretariat, but I would like to maybe ask you just as a favor to give me your sense of how you think that -- I know, we'll send it to you-- that legislation might, if at all -- and it may not, have a positive impact on these larger problems because there is a whole lot of things that flow from the treatment of women essentially as second-class citizens, property and the like.
And I have many more questions but I thank you and I yield to the Senator from Indiana, the chairman.
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SEN. BIDEN: Can I ask a point of clarification on that, if I may?
Senator Lugar makes a very good point about certainty of funding, but in this new round, we are going to consider any increased funding not only being used in the countries that are focus countries, but maybe other countries. Does that create any uncertainty in those very countries?
MR. DYBUL: It's a very good question. However, we have said, and I think you would agree, that we would not reduce funding in any of those countries going forward, because that would be a very difficult position for us and for them.
SEN. BIDEN: I agree. I think you shouldn't. I just wanted to make sure (off mike).
MR. DYBUL: Yeah. What it does also create is a sense of healthy competition, in a sense.
SEN. BIDEN: No, I'm not suggesting it's bad. I just wanted to make sure I --
MR. DYBUL: Yeah. Because we continue -- that's not an issue.
SEN. BIDEN: That's good.
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SEN. BIDEN: Mr. Dybul, I'm impressed with your -- not only with your knowledge, but your commitment to making this program work. Let me ask you -- and I have a number of questions as well, probably half a dozen, I'm going to submit in writing.
But I'd like to conclude by asking you to talk to me about how you envision the coordination between the rest of the world getting into this fight, and this program. I mean, in other words, how much interfacing is there between you and your colleagues in Europe? The decision is made to put X number of dollars in country Y. Is that coordinated in any way with the Europeans? Talk to me about that for just a few moments, on the record.
MR. DYBUL: Yeah, I think that's a great question. I can begin by saying this morning I met with the junior minister from DIFD to talk about some of these issues. Two weeks ago I was in Haiti with the head of the Global Fund. We've taken two joint missions together, Cote d'Ivoire and Haiti. He speaks French; I don't, so I was at a significant disadvantage in two French-speaking countries. But we are trying to do exactly that, and I think we've seen great successes.
Now, there are two pieces of that. One is the global interaction together, and we actually have called a meeting between the Global Fund, myself, the people at the -- in the United Kingdom, the head of the World Bank for these programs and others -- in December or January, to talk more about how we can do this. But the real key is in-country.
The real key is how are we coordinating our programs so that we are supporting one national strategy, and I think we've got some great successes over the last three years. If you look in Ethiopia, if you look in Rwanda, what you see is the Global Fund, for example, PETFAR, and the World Bank jointly coordinated to support the national strategy, where we each do pieces of the puzzle to expand the national program. And that's the thing we need to do more and more of and get better and better at.
So I think we've made great strides, both at the headquarters level and at the country level. But it's one of our principal focuses going forward, because otherwise, we're duplicating effort. Otherwise, we're not effectively supporting the national strategy. And so there are opportunities here, and to be honest, for the American taxpayer, this is a great way to do it, because we're all in it together. We're all in it supporting together, not one piece being the most central or pieces that we can't sustain over the long term. So --
SEN. BIDEN: How many countries --
In the beginning of this whole initiative -- matter of fact, 10 years ago when we started discussing this -- one of the difficulty was the engaging in, you know, the willing suspension of disbelief in some countries where -- there were some countries, which I will not go into name, because it will cause controversies again -- who either denied the existence of the problem in their country, slow to react to it, or when they reacted to it reacted to it in a less than helpful way.
You say countries have national strategies. I imagine a number of the countries, some of which you've already mentioned, need some guidance in developing their national strategy. Is there a go-to agency that countries are inclined to, once they've reached -- they've crossed the Rubicon that they have a problem and they have an obligation to deal with it?
I mean, how does -- how and if you -- Do you, and how do you try to help develop national strategies? Or do you? Not you alone; I mean --
MR. DYBUL: Absolutely. I have to say there is no one particular go-to. There are a lot of international guidance and documents to help direct people, but each country does it differently. And they tend to pool everyone together, to come together to develop one national strategy.
South Africa actually just put forward a great national strategy. Ethiopia has a new one; Kenya has a new one. So they evolve over time, and they're getting better all the time. So that is a principal part of our work, to work with our other partners in- country to build a national strategy that ultimately is owned by that government in that country. So it is a principal part of what we do, and they're improving all the time.
Again, we've only been at it for three years, but it's getting better all --
SEN. BIDEN: I realize that, and I -- look, I, as I said, I'm a fan. I think you're doing a very good job. As I said, I'm impressed.
One of the things I'd like you to submit for the record, if you would -- I'm not looking to make unnecessary work for you here. But if you could lay out for us what is the informal, if not formal, coordinated process that goes on for all the countries, in the Global Fund and this fund, for attacking basically the same problem. They're slightly, there's nuanced differences, and how --
It would be a useful tool for us, for those of us who've been so supportive of this effort to be able to have, to make the case to our colleagues -- and I'm just asking you to do my work for me. I'm asking you to help me lay out the most persuasive document to -- it need not be a document -- most persuasive paper to indicate that we are multiplying, in effect, our dollars. We are not -- we're not duplicating the dollars. Would you be willing to try and take a shot at that?
MR. DYBUL: Absolutely, Mr. Chairman. Your work is our work, so we're happy to do that.
SEN. BIDEN: All right. Well, thank you very much. I appreciate your time and your commitment.
The hearing is adjourned. (Strikes gavel.)